Abstracts of scientific papers. (P-U).

Section on Pathology

THERAPEUTIC APHERESIS: TEN YEARS' EXPERIENCE IN A TEACHING HOSPITAL. Sang Wu, MD, Deepali Gupta, MD, and Elizabeth Hartwell, MD. University of Texas Houston Medical School, Houston, TX.

Therapeutic apheresis (TA) plays a significant role in the treatment of numerous hematologic, neurologic, renal, metabolic, autoimmune, and rheumatic diseases. The field of apheresis continues to evolve due to emerging treatment options and new data from ongoing clinical trials. We attempt to evaluate the distribution, efficacy and complications of therapeutic apheresis in a large teaching hospital for the past decade. We performed a retrospective study of 2,187 therapeutic apheresis procedures involving 276 consecutive patients referred to a university-associated hospital (694 beds; level I trauma center) from 1991 to 2000. All procedures were conducted with the COBE Spectra Apheresis System (Gambro BCT, Lakewood, Colo.). The indication categories for TA have been previously described by the American Association of Blood Banks and the American Society for Apheresis. Efficacy for specific disease entities was assessed with laboratory values and clinical evaluation, when available. Complications were defined a s major or minor by criteria similar to previous studies. Plasmapheresis accounted for the majority (92.3%) of the apheresis procedures, with 220 of the 276 patients. undergoing this procedure. The most common conditions treated with plasmapheresis were: thrombotic thrombocytopenia purpura/hemolytic-uremic syndrome (TTP/HUS) in 52 patients (38.7% of procedures); Guillain-Barre syndrome (GBS) in 40 patients (11.1% of procedures); myasthenia gravis (MG) in 28 patients (8.5% of procedures); and renal allograft rejection in 23 patients (13.0% of procedures). Forty-two patients had red cell exchange, a majority with sickling disorders, accounting for 6.2% of total apheresis procedures. Nine patients (0.9% of procedures) underwent plateletpheresis, and five patients (0.6% of procedures) underwent leukopheresis. Overall, 215 patients (77.9%) experienced clinical improvement. Minor complications were encountered in 52 patients (18.8%), and major complications were encountered in 11 patients (4.0%). Therapeutic aphere sis remains an integral part of the treatment protocol for many disease processes. In the past decade, consultations for TA were requested most frequently for patients with TTP/HUS, GBS, and sickling disorders. Complications and indications for therapeutic apheresis must be considered prior to performing the procedure.

MAMMARY TUBERCULOSIS. Mihai S. Jalba, MD, PhD, Elmira Ibraim, MD, and Dumitru Ghius, MD. Brooklyn, NY.

Mammary tuberculosis is a rare occurrence. Currently, there are about 500 cases of mammary TB published, but few of them during recent years, due to a decrease in endemic tuberculosis in the developed countries. From about 11,000 cases of tuberculosis reported in Romania in the first six months of the year 2000, only two, both without prior TB, were mammary tuberculosis. The first case, a 63-year-old woman, remarked that the lateral 1/3 of the right nipple's circumference and the adjacent skin about one inch behind the nipple was reddened. A discrete pain and a small amount of yellow nipple discharge accompanied this. Mammography showed homogeneous, well-delimited subareolar patches of moderate size, with a fibrous, granular structure (ductal ectasia). The diagnosis was suspicion of right mammary tumor, and a quadrantectomy was done. Pathologic examination showed active intracystic papillomatosis. During the following four months, a tumor progressively developed at the level of the surgical incision. Three mo nths after the quadrantectomy, a second mammogram showed a tumor with an irregular shape and a diameter of 25 to 30 mm. Mammectomy and level 1 and level 2 axillary lymphadenectomy were done as a second surgery. Pathologic examination detected, in addition, a chronic, granulomatous inflammation with areas of necrosis and lipogranuloma consistent with a TB lesion of the nipple in the removed breast. 15 examined lymph nodes were not invaded. The patient was diagnosed with mammary TB, registered as a new TB case, treated with an antitubercular drug regimen, and was eventually cured. This patient diagnosed with mammary tuberculosis and papillomatosis, also had a history of hypothyroidism and major depression. The second patient was a 26-year-old woman. Painless mammary nodules, with a diameter of 25 mm in the right breast and 50 mm in the left breast were detected after she gave birth, and were interpreted as mastitis of lactation. After 1 year, an acute, painful inflammation appeared in the right breast. Quadrant ectomy was done, and pathologic examination showed chronic inflammation, intra- and periductal fibroadenoma, diffuse sclerosis bilaterally, and a TB lesion in the right breast. The patient was successfully treated with an antitubercular drug regimen. Generally, TB mastitis presents in one of three ways: painless breast mass, breast edema, or localized abscess. The skin and axillary lymph nodes may be involved. In our patients, primary TB was associated with a significant background of histologically benign and malignant lesions.

ACANTHAMOEBA CASTELLANI ENCEPHALITIS IN A BONE MARROW TRANSPLANT RECIPIENT MIMICKING A FUNGAL ABSCESS. Amilcar A. Castellano-Sanchez, Aimee C. Popp, Frederick S. Nolte, Govinda S. Visvesvara, Michael Thigpen, Jyoti Soumani, Istivan Redei, and Bruce Wainer. Departments of Pathology and Laboratory Medicine and Medicine, Infectious Disease Division, and Hematology-Oncology Division, Winship Cancer Institute, Emory University School of Medicine, and National Center for Infectious Diseases, Centers for Disease Control, Atlanta, GA.

Free-living, amphizoic amebae of genera Naegleria, Acanthamoeba, and Balamuthia can cause central nervous system infection in humans. We describe a case of Acanthamoeba encephalitis in a 45-year-old Caucasian man with acute myelogenous leukemia who was had undergone haploidentical peripheral blood stem-cell transplant. The patient had stem cell transplant 140 days before presentation. He was not taking any immunosuppressive drugs and had no history of graft-versus-host disease. He came to the emergency department complaining of nausea, vomiting, and occasional episodes of confusion; additionally he had right-sided flank pain without urinary symptoms and a chronic cough since he had the transplant. No headaches, fever, or chills were noted. Medications at the time included megestrol, potassium, citalopram, lansoprazole, albuterol/ipratropium, and vancomycin. Vital signs at physical examination were in normal range, except that he had orthostatic hypotension. Neurologic examination disclosed an orientated male in mild distress, with no motor, sensory, or cranial nerve deficits, and was remarkable only for slow but adequate responses to questions. Laboratory values included normal electrolyte levels and a hemoglobin value of 11.5 g/L with normal white blood cell and platelet counts. A CT scan of the brain showed pansinusitis and a hyperdense lesion along the corona radiata, suggestive of a fungal abscess. Subsequent MRI showed multifocal areas with mass effect in the posterior fossa and parietal and occipital lobes. The patient had worsening respiratory failure and died three days after admission. Gross examination of the brain demonstrated multiple hemorrhagic, punctate lesions in cortical, subcortical and cerebellar sections. Prominent perivascular acute and chronic inflammatory infiltrate was found on microscopic examination. Within the infiltrate, large "histiocytoid" -appearing amebic trophozoites with prominent, round, eccentric nuclei with eosinophilic, periodic acid-Schiff-stain-positive cytoplasm were seen. Amebae tended to infiltrate and destroy blood vessel walls. No meningeal involvement was identified. Immunofluorescent staining of the tissue performed at the CDC identified the ameba as Acanthamoeba castellani. To the best of our knowledge, this is the only case in which this species of Acanthamoeba has caused encephalitis in the setting of bone marrow transplantation.

Section on Pediatrics and Adolescent Medicine

DOCUMENTATION OF VACCINATION AND PERFORMANCE OF TRANSCRANIAL DOPPLER (TCD) IN CHILDREN WITH SICKLE CELL DISEASE (SCD). Zarin Golshani, D. Ode, MD, C. Kallen Gowder, MD, M. Velez, MD, and R. P. Warner, MD. LSU Health Sciences Center and Children's Hospital, New Orleans, LA.

Advances in immunizations, transfusion practices, and acute care have decreased the mortality and morbidity rates of sickle cell disease in children. Poor documentation and ignorance of immunization status is often a deterrent to care. We reviewed the medical records of 234 children with SCD at Children's Hospital of New Orleans to assess the level of documentation. Documentation of immunizations is inadequate and needs to be improved. Use of centralized and computerized methods may be warranted. TCD tests are well documented because they are done at one site by the hematology/oncology team.

ANALYSIS OF CAUSES OF FEVER AND ASSOCIATED COMPLICATING FACTORS IN CHILDREN WITH SICKLE CELL ANEMIA: PRELIMINARY RESULTS. Kelly J. Cramm, MD, David L. Ode, MD, Maria Y. Velez, MD, Lolie C. Yu, MD, Raj P. Warner, MD, and Renee V. Gardner, MD. Louisiana State University Health Sciences Center, New Orleans, LA.

Patients with sickle cell anemia (SSD) are at risk of life-threatening infections because of asplenia. It is unclear whether use of penicillin prophylaxis and pneumococcal vaccination alters the incidence of bacterial septicemia. We performed a chart review of 197 admissions involving 48 patients with SSD having documented fever > 38[degrees] C over 5 years at Children's Hospital. The following events were observed: four (2%) positive blood cultures (2 Streptococcus pneumoniae, 1 Klebsiella pneumoniae, 1 Salmonella species); 1 case of osteomyelitis (0.5%); 4 (2%) urinary tract infections, (1 Escherichia coli; 1 Staphylococcus aureus, 1 K pneumoniae, 1 Pseudomonas aeroginosa. Pneumonia was documented on chest x-ray film in 25 events (12.7%), with positive Mycoplasma titers in 1 (0.5%). Sinusitis was documented radiographically in 7 events (3.6%). Clinical examination (no tympanocentesis) revealed otitis media in 14 events (7.1%). Viral infection was suspected in 61 episodes. Documentation of viral pathogens wa s positive in 26 events (5 influenza A (1.5%); 3 influenza B (0.5%); 2 parainfluenza (1%); 2 adenovirus (1%); 10 respiratory syncytial virus (5%); 1 rotavirus (0.5%); 1, varicella zoster pharyngitis (0.5%). One individual was found to have Clostridium difficile (0.5%). Folliculitis with MRSA was noted in one patient (0.5%). No deaths occurred. Ols regression analysis revealed a positive correlation between higher WBC counts and severity of infection, positive blood cultures, longer antibiotic course, and longer hospital stay (P = .006). Complicating factors of cholelithiasis, splenic sequestration, pain crisis, priapism, and aplastic crisis were noted in 38 (19.3%) of the admissions, and those patients were less likely to have severe infections. In conclusion, the majority of patients (59%) had no identifiable source of infection. However, bacteremia was seen in children < 2 years of age and was associated with temperature >39.3[degrees] C and WBC count > 15,000/[micro]L. Our results suggest that current crit eria for institution of antibiotic therapy in the sickle cell patient with fever warrants further review.

EVALUATION OF CRYING IN A PEDIATRIC EMERGENCY DEPARTMENT. Antonio E. Muniz, MD. Department of Emergency Medicine and Pediatrics, Medical College of Virginia of VCU, Richmond, VA.

Inconsolable crying in infants and children is a common presentation to an emergency department. Crying is the means by which an infant may express discomfort, ranging from normal hunger to more severe, life-threatening illnesses. Excessive crying may exert a serious impact on the parents' lives. The present study reviews the epidemiology of crying visits to a pediatric emergency department.

Methods: We prospectively evaluated all children less than 18 years of age who presented to the pediatric emergency department from 8/1998 to 8/2001 with a chief complaint of crying. There were 322 children. The median age was 1.7 years (range, 4 days to 18 years). There were 176 males (54.6%), 256 (79.5%) African Americans, 41 Caucasians, 17 Hispanics, and 8 Asians. There were 65 different diagnoses. The most common diagnoses included acute otitis media (28.5%), viral illness (22.9%), upper respiratory illness (13.3%), nonspecific crying (10.8%), and colic (7.4%). There were 12 (3.7%) serious diagnoses, which included: intussusception (n = 4), sepsis (n = 3), fractures (n = 3), biliary atresia (n = 1), and acute life-threatening event (n = 1). There were 177 (54.9%) incidences of abnormal vital signs, with fever accounting for 74 (22.9%) and tachycardia accounting for 29 (9%). Only six (1.8 %) children arrived by emergency medical services transport. There were 8 (2.4%) admissions. Crying is a common complai nt; however the majority of children will have benign etiologies. A thorough history and physical examination should be performed to exclude serious causes.

STURGE-WEBER DISEASE PRESENTING AS AN ACUTE LIFE-THREATENING EVENT. Antonio E. Muniz, MD. Department of Emergency Medicine and Pediatrics, Medical College of Virginia of VCU, Richmond, VA.

Sturge-Weber Disease is an unusual cause for an acute life-threatening event (ALTE). It usually presents as seizures, hemiplegia, and a classic facial rash. Careful physical examination of a neonate with ALTE may reveal unusual causes, such as in this case. A 2-day-old female was brought to the ED after 2 events of becoming lethargic, limp, and having central cyanosis. Each episode lasted less than 1 minute, and resolved with stimulation. While in the ED, she had an episode of tonic-clonic movements lasting 20 seconds. Her birth history and medical history were unremarkable. She took no medications. She was breast fed. Her physical examination was remarkable in that she was pale. She had scleral icterus. She had a faint, erythematous patch on her right face. She had a temperature of 36.7[degrees]C; heart rate, 140 beats/min; respiratory rate, 34 breaths/min. Her WBC count was 14,000/[mm.sup.3] with 36 % neutrophils and 7 % bands. Her hemoglobin level was 18.5 g/dL and platelet count was 324,000/[mm.sup.3]. He r electrolyte levels were normal. Her unconjugated bilirubin value was 8.8 [micro]mol/L. Chest radiograph was normal. Head CT revealed abnormal calcification in the right occipitoparietal region. She was admitted and treated with phenytoin. The urine, blood, and CSF cultures were negative. Sturge-Weber disease, or encephalotrigeminal angiomatosis, is characterized by a congenital capillary hemangioma, which usually unilaterally involves the face and cervical area, mucous membranes, meninges, and choroid. The skin angioma, or nevus flammeus ("port wine stain"), is the most characteristic external clinical feature, and is typically found in the trigeminal nerve distribution. In the meninges, the malformation is confined to the plial vessels in the occipitoparietal areas. Blood flow becomes sluggish, which leads to anoxic injury of the underlying cerebral cortex. This is manifested clinically as convulsions, mental retardation, hemianopsia, or hemiparesis. Occasionally, a subarachnoid hemorrhage may occur. Radio graphically, skull x-ray films may show calcifications ("railroad track pattern") in the damaged areas. Angioma in the choroid may lead to glaucoma. Treatment consists of anticonvulsants for seizures, physiotherapy for paretic limbs, and periodic eye examinations for glaucoma. Severe refractory seizures may require surgical resections.

MULTIPLE CRANIAL NERVE NEUROPATHIES AND ATAXIA: MILLER FISHER SYNDROME. Antonio E. Muniz, MD. Department of Emergency Medicine and Pediatrics, Medical College of Virginia of VCU, Richmond, VA.

Miller Fisher syndrome is a Guillain-Barre syndrome variant characterized by the triad of internal and external ophthalmoplegia; cerebellar ataxia; and areflexia. It traditionally occurs after an influenza B infection. This is the case of a child with a severe form of this disorder requiring intubation. A 5-year-old girl presented to the ED with a 2-week history of difficulty walking, diplopia, and dysarthria. There was no fever, trauma, or recent viral illness. She was hospitalized at another hospital and had reportedly had unremarkable head CT and MRI, CSF studies, and EEG. She was discharged with no diagnosis. Medical history included asthma, otitis media and PE tube placement. Her medications included albuterol and nystatin. She had a temperature of 37.8[degrees]C; heart rate, 88 beats/min; and respiratory rate 20 breaths/min. Physical examination was significant for oral thrush. Her neurologic exam showed a disconjugate gaze, right-sided nystagmus, ataxia, and dysmetria. She had palsy of cranial nerves I II, IV, V, VI, X, and XI. DTRs of the lower extremities were not present. WBC count was 9,500/[mm.sup.3] with 77% neutrophils. Her hemoglobin level was 10.6 g/dL and platelet count was I95,000/[mm.sup.3] Her electrolyte levels were normal. CSF examination was repeated and showed an elevated protein level. Her respiratory status worsened, requiring intubation. She could not be weaned off the ventilator and required a tracheostomy. MRI of the head was repeated and was nonspecific. She was given IV IgG and her symptoms slowly responded. She was discharged to the Children's rehabilitation hospital and recovered well. Miller Fisher syndrome is associated with antiGQ1b IgG antibody. GQ1b, a tetrasyaloganglioside is enriched in the cranial nerves that innervate the extraocular muscles. The classic cranial nerve abnormality is ophthalmoplegia; however, other cranial nerves may be involved. Other associated features may include pupillary abnormalities and blepharoptosis. Treatment for this condition involves either pl asmapheresis or intravenous immunoglobulins. Patients with MFS usually have a good prognosis and no residual deficits.

FEVER IN A 10-WEEK-OLD INFANT DURING RSV SEASON: AN UNUSUAL PRESENTATION OF ACUTE LYMPHOBLASTIC LEUKEMIA. Antonio E. Muniz, MD. Department of Emergency Medicine and Pediatrics, Medical College of Virginia of VCU, Richmond, VA.

Acute lymphoblastic leukemia (ALL) is the most commonly diagnosed malignancy in children. The peak incidence is between 2 and 6 years of age, and it is rare in children less than 3 months of age. Young infants who present with fever usually undergo a full sepsis evaluation, which includes a complete blood cell count. We present the case of a young infant with fever during the peak of RSV season and newly diagnosed leukemia. Few investigators have suggested that young infants with fever during RSV season may only require detection of RSV as their initial diagnostic evaluation. If their test for RSV is negative, then a full sepsis evaluation may be required. If the RSV test had been positive in the infant, her diagnosis of leukemia may have been delayed. It is imperative to diagnose neonatal leukemia early in order to initiate treatment and improve the prognosis. A 10-week-old female presented with a 1-day history of fever, rhinorrhea, poor feedings and decreased urinary output. There was no vomiting, diarrhea, dyspnea, petechia, or purpura. Her birth history, medical history, and family history were unremarkable. She took no medications. She had a temperature of 38.6[degrees]C; blood pressure, 110/52 mm Hg, heart rate, 140 beats/min; and respiratory rate, 40 breaths/min. Physical examination was remarkable for mild hepatomegaly and no obvious bacterial source for her fever. Her RSV test was negative. WBC count was 217,000/[mm.sup.3] with 34 % blasts. Electrolyte levels were normal. Urinalysis, cerebrospinal fluid analysis, and chest radiograph were unremarkable. She was randomized to chemotherapy protocol POG #9407. Induction agents included vincristine, daunorubicin, cyclophosphamide, intrathecal methotrexate, and cytosine arabinoside (ARA-C). Supportive therapy included mesna, G-CSF, trimethoprim/sulfamethoxazole and fluconazole, nafcillin, and tobramycin. She received multiple transfusions of PRBCs and platelets, and overcame Haemophilus influenzae sepsis. She recovered and is doing well 2 years later. ALL affe cts the bone marrow and leads to proliferation of immature lymphoid cells, which leads to the characteristic signs and symptoms. The first symptoms are nonspecific and difficult to recognize. The most common presenting symptoms include fever, pallor, purpura, and pain. Laboratory evaluation may reveal anemia, thrombocytopenia, and abnormally high numbers of abnormal leukocytes. Diagnosis is established by bone marrow examination. Neonates with leukemia have a poor prognosis,, especially if initial WBC count is greater than 50,000/[mm.sup.3] when compared with leukemia in childhood, and aggressive chemotherapy has improved their survival.

Section on Psychiatry & Neurology

ASSOCIATION BETWEEN RELATIVE TACHYCARDIA AND POOR OUTCOME IN ACUTE ISCHEMIC STROKE. Sina Ehasani, MD, A. Naidech, MD, and Leon A. Weisberg, MD. Tulane University Health Sciences Center, New Orleans, LA.

The degree of sympathetic tone after stroke may relate to its severity. We sought to clarify this relationship using heart rate as a measure of sympathetic activation in cases in which there was no alternative explanation for the measured heart rate. We reviewed the charts of all stroke patients admitted to the Tulane service at Charity Hospital New Orleans in 2000. Information on heart rate within 48 hours of stroke onset and Rankin scale score on discharge were abstracted. Patients with GI bleeding, cardiac pacemakers, atrial fibrillation, and patients who received tPA were excluded. Data were available on 82 patients. The mean heart rate for patients who were not independent (Rankin score > 3) was 81.7 vs 73.6 in those who could walk with a device or better (P = .001). This finding remained constant after controlling for comorbidities and the use of heart-rate altering medications. Worse outcome and higher heart rates were observed in patients with cortical lesions, but there was no relationship to lateral ization of the lesion to one hemisphere. These data support the hypothesis that relative tachycardia is associated with worse outcome in ischemic stroke. Further research might focus on more directly measuring sympathetic tone and perhaps on sympatholytic therapy as a treatment.

THE PREVALENCE OF PSYCHIATRIC DISORDERS IN PATIENTS WITH CHRONIC HEPATITIS C. Muhamad Aly Rifai, MD, James K. Moles, MD, Brian Van der Linden, MD, MPH. University of Virginia, School of Medicine, Roanoke-Salem. Veterans Affairs Medical Center, Salem, VA.

It is estimated that 4 million Americans are chronically infected with the hepatitis C virus (HCV). An appreciation of the burden of psychiatric illness in patients with hepatitis C infection is of more than academic interest. Early recognition and treatment of psychiatric disorders in HCV+ patients is important to the course and management of hepatitis C, as well as to the psychiatric disorder itself Newer forms of interferon-2a(IFN) therapy are more effective in the treatment of chronic HCV infection; however IFN therapy is complicated by a host of neuropsychiatric side effects. Active psychopathology may also interfere with compliance, rendering these medications ineffective or precipitating adverse reactions. We assessed the prevalence of psychiatric disorders in a sample of HCV+ patients at a Veterans Affairs Medical Center, in Salem Virginia. Medical records of 400 randomly selected HCV+ (by EIA II) patients were reviewed for past and present DSM-IV-based psychiatric disorders. A similar group of random ly selected patients who were HCV- negative was utilized as a control. Each psychiatric diagnosis was independently confirmed (by 2 reviewers) with DSM-IV criteria, utilizing symptoms recorded in the chart. Only the diagnoses that could be independently confirmed were included for analysis. The prevalence rates of psychiatric disorders in the HCV+ vs HCV-negative patients are presented as follows: Mood disorders 38% vs 17%; personality disorders, 30% vs 7%, post-traumatic stress disorder, 19% vs 13%; and psychotic disorders, 17% vs 4%. Alcohol abuse/dependence disorders were found in 86% of HCV+ patients vs 23% of HCV-negative patients. Our data indicate that prevalence rates of a variety of psychiatric disorders are higher in patients with hepatitis C than in the control HCV-negative patients in the same health system (Department of Veterans Affairs Health System) and the general US population (ECA data). Mood, anxiety, personality, and psychotic disorders were all relatively common in these patients. Psychi atric disorders may influence the course and treatment of hepatitis C infection, and psychiatrists should be aware of the substantial psychiatric comorbidity in patients with this infection. Psychiatrists should become aware of the substantial psychiatric comorbidities in patients with chronic HCV infection, since they impact its course and treatment. Since newer and more effective treatments for HCV infection are becoming available, psychiatrists may be asked to help identify patients to be screened for HCV and manage the psychiatric comorbidities of HCV+ patients receiving IFN.

SWITCHING STRATEGY FOR ADOLESCENTS WITH EXCESSIVE WEIGHT GAIN WHILE TAKING OTHER ATYPICAL ANTIPSYCHOTICS TO ZIPRASIDONE: SAFETY, TOLERABILITY, AND EFFICACY WITH ASSOCIATED WEIGHT LOSS. Steven A. Gleckler, MD. Evansville, IN.

This retrospective chart review of a cohort of 8 adolescents hospitalized in a hospital-based residential treatment program examines the safety, tolerability, efficacy, and subsequent weight loss after they had their medications switched from either risperidone, olanzapine, or quetiapine to ziprasidone. Seventeen adolescent patients on the same unit had gained significant weight while taking other atypical antipsychotic agents (10 patients gained a combined total of 291 pounds during a total of 77 months while taking risperidone; 5 patients gained a combined total of 220 pounds during a total of 77 months while taking olanzapine; and 2 patients gained a combined total of 27 pounds during 11 months of taking quetiapine). Of these 17 patients, 8 had their medication switched from their original atypical antipsychotic to ziprasidone due to excessive weight gain. Over the course of 6 months, these 8 have lost a total of 57 pounds. While taking risperidone, 3 patients had gained an aggregate 82 pounds, but since s witching to ziprasidone have lost a total of 32 pounds. While taking olanzapine, 3 patients had an aggregate 104 pounds, but since switching to ziprasidone have lost a total of 24 pounds. While taking quetiapine, 2 patients had gained an aggregated 27 pounds, but have lost 5 pounds after switching to ziprasidone. Modest QTc interval increases ranged from 6.1 to 9.5 msec. No changes were observed in fasting glucose levels. All patients tolerated the switch to ziprasidone without any safety or tolerability issues. Efficacy was demonstrated by a reduction in frequency and severity of dangerous behaviors, and in the frequency of prn medications used. Conclusion: In this open-label study, switching the medications of overweight adolescents from other atypical antipsychotic agents to ziprasidone was safe, easily tolerated, efficacious, and led to significant weight loss for all 8 patients. Ziprasidone appears to reverse the weight gain that adolescents frequently experience with all other atypical antipsychotic age nts (risperidone, olanzapine, and quetiapine).

Section on Radiology

FDG PET--A CRUCIAL COMPONENT OF INITIAL EVALUATION OF PATIENTS WITH SOLITARY PULMONARY MASSES. Mohab Alexander, MD. Department of Radiology, Johns Hopkins University, Towson, MD.

An 80-year-old man presented to the clinic with shortness of breath so severe that he could not perform the activities of daily living. Chest radiograph and computed tomography (CT) of the chest demonstrated a 30-cm left chest mass extending inferiorly to displace the left kidney and spleen. Three incisional biopsies yielded inconclusive results. Positron emission tomography (PET) with [18F] fluorodeoxyglucose (FDG) ruled out a malignancy, so a curative excisional biopsy was performed. We conclude that FDG PET is a crucial component of the initial evaluation of patients with solitary pulmonary masses.

PACS-BASED RADIOLOGIC PRESENTATIONS AND CONFERENCES. W. M. Flowers, A. J. Fertitta, S. W. Harrison, R. F. Brown, G. T. Vanderslice, and R. K. Hays. The University of Mississippi Medical Center, Jackson, MS.

This presentation demonstrates how a picture archiving and communication system (PACS) directly connected to a personal computer (PC) is used to produce digital radiologic presentations and conferences. A PACS system is connected to a laptop computer and to a conference-room desktop computer with Ethernet technology. State-of-the-art software and hardware are used to produce and incorporate radiographic images from a PACS system directly into radiologic scientific-paper presentations, lectures, and teaching conferences. No cameras, film, chemicals, or scanners are needed. Radiographs can be shown as either conventional static images or as motion pictures, for example, scrolling. Images maintain excellent resolution. The direct connection of a PACS system with a PC and state-of-the-art software results in an efficient and powerful new teaching tool.

DIGITAL VIDEO FOR MEDICAL PRESENTATIONS AND CONFERENCES. W. Mel Flowers, Jr., G. T. Vanderslice, R. F. Brown, S. W. Harrison, R. K. Hays, and A. J. Fertitta. University of Mississippi Medical Center, Jackson, MS.

This presentation demonstrates how we make and insert movies into PowerPoint presentations. A digital video camera is used to record motion pictures. Firewire technology and a video-capture card allow transfer of the video clips into a personal computer. Editing software is utilized to format the images. The resulting product is simply inserted directly into the slide show. Digital video is used to great advantage in the demonstration of technical procedures and processes. State-of-the-art computer hardware and software allow the mixture of static images, text, sound, and video within the same presentation, and even on the same slide. This technology is straightforward and readily available. Video clips in PowerPoint presentations are effective and efficient teaching tools.

Tc99m-DEPREOTIDE IMAGING OF CARDIAC SARCOIDOSIS. Erik S. Storm, DO, David A. Kristo, MD, Jaime L. Montilla, MD, and Robert S. Bridwell, MD, MBA. Walter Reed Army Medical Center, Washington, DC.

Sarcoidosis is an inflammatory granulomatous disease of unknown etiology. Cardiac sarcoidosis is a relatively rare extrapulmonary manifestation, which can prove life-threatening if left untreated. While myocardial tissue biopsy is the gold standard for diagnosis, noninvasive techniques, including nuclear imaging, are often employed to aid in the diagnosis and to monitor disease progression. Somatostatin-receptor scintigraphy has recently proven useful in the initial assessment and follow-up of granulomatous disease, including sarcoidosis. Tc99m-depreotide (NEOTECT) is a newly approved radiopharmaceutical designed to detect overexpression of somatostatin receptors 2, 3, and 5 on anatomic tissue. It is approved for use in Europe and the United States for the evaluation of the malignant potential of pulmonary nodules. We report the use of Tc99m-depreotide compared with gallium-67 scintigraphy in a patient with presumed cardiac sarcoidosis. Follow-up studies again utilizing Tc99m-depreotide are also presented to demonstrate the ability to detect response to therapy and subsequent relapse. Our patient is a 31-year-old white man who originally presented in January 2001 with decreased exercise tolerance and an abnormal CXR. He underwent transbronchial biopsy with pathologic findings consistent with noncaseating grantilomas. His EKG was normal, and he was followed up clinically for the next several months without treatment. In August 2001, the patient complained of worsening dyspnea on exertion. An exercise stress test at that time revealed a new RBBB. Consultation with the nuclear medicine service was requested. Planar and SPECT scintigraphy, using both Tc99m-depreotide (20 mCi) and Ga-67 (5 mCi), demonstrated abnormalities in the perihilar nodal distributions. In addition, Tc99m-depreotide demonstrated increased radiopharmaceutical uptake within the left ventricular myocardium, consistent with cardiac sarcoid. The patient was subsequently given a 5 1/2-month course of prednisone. In November 2000, approximately halfway through his treatment course, he became clinically asymptomatic and was re-imaged with Tc99m-depreotide (20 mCi). This study demonstrated near-complete resolution of the previous abnormal uptake. The patient completed his treatment course in mid-January 2002. In February 2002, the patient again complained of worsening DOE, however not to the degree he had previously experienced. An echocardiogram at that time was essentially normal, with an EF of 50%. The patient continued to have worsening symptoms, and in March 2002 was again imaged with Tc99m-depreotide (20 mCi). This study demonstrated a marked recurrence of abnormal radiotracer uptake both within the perihilar nodes and again within the left ventricular myocardium. Additionally, mild cardiac enlargement was present, which was new finding from previous examinations. Tc99m-depreotide may be a useful adjunct in the diagnosis and follow-up of patients with extrapulffionary sarcoidosis. In the presented case, presumed symptomatic cardiac sarcoidosis was dete cted with Tc99m-depreotide, but was not demonstrated with gallium 67, a common radiopharmaceutical used in detection of granulomatous disease. Further studies are needed to evaluate the full potential of Tc99m-depreotide in the imaging of patients with sarcoidosis.

Section on Rheumatology

REACTIVE ARTHRITIS FOLLOWING BACILLE CALMETTE-GUERIN (BCG) THERAPY Jeri Mao, MD, and Paul A. Wehrle, MD. William Beaumont Army Medical Center, EL Paso, TX.

BCG is a commonly used intravesical agent for treatment of superficial bladder cancer. Because the therapeutic mode of action involves an inflammatory reaction of the bladder, this treatment is associated with various side effects. Serious systemic side effects were quite rare. 0.5% of patients develop arthritis. We describe a case of polyarthritis associated with intravesical BCG therapy. A 64-year-old white man with superficial bladder cancer diagnosed in 1998, had BCG therapy in February 1999. In early March, he complained of overnight swelling and pain in the left second MCP, followed by low-back pain with stiffness all day. The pain was minimally responsive to Feldene. His bone scan and MRI showed some degenerative disk disease without evidence of metastatic bone disease. In April, his right knee suddenly swelled up and became quite warm and inflamed. On physical examination, he had 2+ synovitis at the left second MCP with good ROM; decreased ROM of lumbosacral spine; 1+ right knee effusion with tenderne ss at right MTP joints. There were no skin or eye lesions. Laboratory findings were WBC count, 14,300/[micro]L; hct, 28.2 mL/dL uric acid, 6.4 mgdL; platelet count, 310 x [10.sup.9]/L; ESR 55 mm/hr; CRP, 5.4 mg/L; CPK, 82 U/L; TSH, 3.64 [micro]IU/L; RF and ANA were negative. Fluid was aspirated from his right knee, and the knee was then injected with 40 mg of Aristospan. SF was negative for crystals. Prednisone 25mg was given, then tapered off, and Celebrex therapy was started. One week later he felt somewhat better, but still had mild symptoms in his right knee. INH with pyridoxine was given for prophylaxis. At one month follow-up, his symptoms were markedly improved without new symptoms. BCG arthropathy is a rare entity. Morning stiffness and symmetric joint pain are the most common pattern. 48% of patients have eye involvement. 66% are HLA-B27-positive. SF reveals an aseptic, inflammatory process. The arthritogenic and cross-reactivity hypothesis is one of the most popular for ReA. In experimental adjuvant arthritis, there is cross reaction by CD4+ T cell between the 65 kDa heat-shock proteins in Mycobacterium bovis and cartilaginous proteoglycans. Molecular mimicry between HLA-B27 and BCG antigenic determinants has been suggested. NSAIDs are the first lines of therapy. Corticosteroids and, antituberculous drugs are also used in some cases. Early diagnosis is important for prompt treatment and good prognosis.

RESOLUTION OF THROMBOTIC ENDOCARDIAL VEGETATIONS FOLLOWING HIGH-DOSE ANTICOAGULATION IN A PATIENT WITH APL SEROLOGY, FACTOR V LEIDEN MUTATION AND ANTIBODIES TO NATIVE DNA. Syed Quadri, MD, and Timothy J. Drehmer, MD. Wright State University School of Medicine, Dayton, OH.

Antiphospholipid syndrome (APS) has been defined as venous or arterial thrombosis, recurrent fetal loss, or thrombocytopenia accompanied by an increased level of antiphospholipid antibodies (aPLs). The syndrome can be primary or due to an underlying condition, most commonly systemic lupus erythematosus (SLE). We report a case of mitral valve thrombus in a patient with aPLs, factor V Leiden, and antibodies to native DNA. An otherwise healthy 47-year-old African American woman presented with acute confusional state. Neurologic evaluation revealed receptive aphasia, right homonymous hemianopia, and decreased cortical sensory modalities of her right upper extremity. Cardiovascular examination revealed a murmur, consistent with mitral regurgitation. There were no clinical stigmata of infective endocarditis. Routine laboratory examination revealed thrombocytopenia (94,000/[micro]L). The prothrombin time was 13.0 seconds, and partial thromboplastin time (PTT) was elevated at 38.1 seconds. VDRL was positive at 1:32 d ilutions. Fluorescent treponemal antibody test was negative. She had a negative urine drug screen, and her urinalysis revealed non-nephrotic proteinuria. Computed tomography of the head revealed an acute infarct. Magnetic resonance imaging of the brain was consistent with an acute infarct that was believed to be embolic in nature . Magnetic resonance angiogram was normal. Transthoracic and subsequent transesophageal echocardiogram showed echo-dense 1-cm masses on both the anterior and posterior mitral valve leaflets on the atrial side, suggestive of vegetations. Six blood cultures were negative for usual pathogens and HACEK group. On the basis of prolonged PTT, mixing studies were done and the patient was shown to have lupus anticoagulant. She was also found to have markedly elevated antiphospholipid antibodies with IgG anticardiolipin antibody level of 52.3 GPL, IgG antiphosphatidyl seine antibody level of 131.5 GPS, and IgG beta 2-glycoprotein level of 175.5 GU. The antinuclear antibody test was negative, w ith a titer < 1:40. Interestingly, she had a markedly elevated antinative DNA antibodies with a titer of 469 IU /ml. Smith antibody and RNP antibody tests were negative. Complement levels and the rheumatoid factor were normal. The protein C, total and free protein S, homocysteine, and antithrombin III levels were normal. Assessment for coagulation abnormalities was remarkable for factor V Leiden being detected as heterozygous. The prothrombin 20210G>A mutation was absent. The patient was started on indefinite, high-dose anticoagulation because of an increased risk of recurrent thromboembolism. The patient was also started on tapering dose of steroids, as ANA-negative lupus was a consideration. Follow-up echocardiogram done after six weeks of full anticoagulation therapy showed complete resolution of the valvular masses. To our knowledge, this is the first reported case of valvular vegetations in association with antiphospholipid (aPL) serology, factor V Leiden mutation, and antibodies to native DNA. The resol ution of the valvular vegetations in response to high-dose anticoagulation therapy supports our theory that these vegetations were thrombotic in nature, rather than Libman-Sacks lesions. Factor V Leiden mutation and aPL are two independent risk factors for venous and arterial thrombosis that rarely coexist in the same patient. The literature supports a role for aPL in the pathogenesis of valvular lesions, especially valve thrombi. The presence of an additional thrombophilic defect, in this case the factor V Leiden mutation, may have a synergistic effect in this patient, further predisposing to thrombotic endocardial lesions. We cannot exclude ANA-negative lupus in this patient, though this entity is considered rare, especially with new human-tissue substrates (< 2% of SLE patients).

Section on Surgery

RECLAIMING GROUND LOST. EXPANDING THE EXPERIENCE OF GENERAL SURGERY RESIDENTS. Danny Little, MD, Seth Fritcher, MD, Marvin Atkins, MD, Randall Smith, MD, Clifford Buckley, MD, Robert Feldtman, MD, and Robert Johnston, MD. Central Texas Veterans Administration, Temple, TX.

The training of surgical residents continues to evolve. Many procedures that were formerly in the domain of general surgery have been acquired by other specialties. Bronchoscopy, liver and kidney biopsy, endoscopy, arteriograms, pacemaker insertion, and endovascular procedures have been forfeited, allowing our nonsurgical colleagues more influence with our patients. Institutional variation has allowed our general surgery residents to actively participate in diagnostic arteriograms, pacemaker insertions, and endovascular procedures. The purpose of this study was to evaluate the outcomes of these procedures performed in our university setting by general surgery residents. The medical and electronic records of all patients undergoing diagnostic arteriograms, pacemaker placements, or endovascular procedures during 2000 (12 months) were reviewed. Procedures performed by nonsurgeons were excluded. Two hundred sixty diagnostic arteriograms were performed on 257 patients. These included 138 aortic arch/four-vessel ar teriograms, 116 aortograms with distal run-off, and 6 renal arteriograms. There were no strokes, false aneurysms, or deaths. Three patients had to be admitted overnight for hypertension management. One patient had a seizure during an aortic arch/four-vessel arteriogram. In addition to the arteriograms, general surgery residents participated in 87 pacemaker and 31 Reveal internal loop recorder placements; 20 iliac and 9 carotid stent procedures; 4 inferior vena cay filter deployments; and 3 endovascular abdominal aortic aneurysm grafts. All cases were performed in the fluoroscopy suite or the operating room. General surgery residents have been shown to have the ability and technical expertise to master diagnostic arteriograms, pacemaker placements, and endovascular procedures. To be competitive in today's marketplace, general surgery residents must be allowed to expand their clinical experience while program directors continue to foster the overall development of these young surgeons.

IMPERFORATE ANUS: ASSOCIATED ANOMALIES, NATURAL HISTORY AND CONSEQUENCES 66 YEARS IN THE MAKING. Raul Cardenas, BS, and Ana M. Grau, MD. Department of Surgery, Meharry Medical College, Nashville TN.

Imperforate anus (IA) occurs in 1 in 5,000 live births. The lesions are divided into high and low types, based on whether the rectum ends above or below the puborectal component of the levator ani complex. We present a case of a patient, with a high IA associated with multiple other anomalies and complicated by colon and bladder/cloacal cancer. Case report: The patient is a 66-year-old man with history of imperforate anus treated with colostomy. He presented with abdominal pain and no output per colostomy. The mucous fistula was saturated with a paste-like material, creating a 13-cm palpable mass. in the abdomen. GU exam was remarkable for hypospadia. Gastrograflin studies revealed an "apple-core" lesion proximal to the colostomy. CT scan demonstrated both kidneys to be on the right side (cross-fused). Left hemicolectomy, distal mucous fistula colectomy, with colostomy and mucous fistula were performed, at which time other anatomic abnormalities were discovered. A cystogram revealed a sessile mass on the blad der and a connection between the distal mucous fistula and the bladder. Biopsy demonstrated an adenocarcinoma of the bladder/cloaca. Pathology of the colon demonstrated a stage II colon cancer. Discussion: The incidence of urogenital anomalies including renal malformations in IA increases with the level of anorectal lesion. Our patient presented with what has been described as partial urorectal septum malformation sequence (URSM), a condition caused by abnormalities of septation of the primitive cloaca. He received no successful surgical treatment, which resulted in persistent colonic mucosa exposure to urine, a condition associated with the development of adenocarcinoma of the colon. We believe the bladder/cloaca adenocarcinoma corresponds to a second primary tumor. Adenocarcinoma development has been described as a complication of cloacal remnants.

ALL-TERRAIN VEHICLE TRAUMA IN GERIATRIC PATIENTS. Bruce D. Adams, MD, Paul Dereska, MD, Regina Medeiros, CCRN, and Michael L. Hawkins, MD. Medical College of Georgia, Augusta, GA.

All-terrain vehicle (ATV) trauma creates about 80,000 emergency department (ED)-treated injuries and 250 deaths annually in the United States. Recently, the incidence of ATV trauma has increased again, most dramatically among older riders. 8% of ATV drivers are over age 55 years, and they account for about 3% of reported injuries nationwide. However, there is limited published data focusing on this population segment. We reviewed our geriatric ATV trauma from 1989-2001. We analyzed the trauma registry from 1989 to 2001 for injury code E821.0-E821.9, corresponding to ATV-related trauma. We found 8 patients over the age of 60 and analyzed the trauma registry and their clinical charts for trends. We compare these patients to the all-ages ATV-trauma cohort. There were 172 total patients of all ages; 81% were male; average age was 25 years and average blood alcohol content (BAG) was 35.1 mg/dL. Averages on ED arrival: RTS, 7.70; GCS, 14.3; SBP = 134 mm Hg; estimated survival probability (ESP) = 0.95. 1-lospital co urse: ICU days = 3.5; hospital LOS = 4.8 days; discharge ISS = 10.8. FIM average discharge scores were: locomotion = 3.74 ; feeding = 3.97; expression = 3.98. There were 8 patients older than 60 years (4.7% of overall), and all of those were men. Average age was 67.9 years and BAC was 3.25 mg/dL. Averages on ED arrival: RTS = 7.37; OCS = 13.4; SBP = 160 mm Hg; ESP = 0.97. Hospital course: ICU days = 3.6; LOS = 7.1; ISS = 11.5. FIM scores: locomotion = 2.86; feeding = 4.00; expression = 3.71. 1 of the 8 patients died; 3 required ED intubation; 6 required surgery; all required hospital observation. The geriatric population was statistically more likely to be male, have higher ED SBP but have a lower FIM locomotion score at discharge. This small cohort of geriatric patients required extensive hospital resources. Most comparative differences do not reach statistical significance because of the small sample size. However the data tend to show that, while elderly patients have a similar level of trauma seventy at E D arrival, they often require longer hospitalizations with more rehabilitation requirements at discharge. We are planning a larger analysis of geriatric ATV patients using national databanks in the future. Community leaders should promote the use of safety equipment and training amongst senior citizen ATV operators.

A SIX-YEAR RETROSPECTIVE REVIEW OF ENTEROCOCCAL SEPSIS IN THE SICU AT HUH: HAVE WE MADE A DIFFERENCE? Eric Valladares, MD, and William Matory, MD. Division of Trauma and Critical Care, Howard, University, Washington, DC.

Vancomycin-resistant enterococci (VRE) have become an increasingly common problem throughout the United States. Vancomycin-resistant enterococci were first described in Europe and subsequently in the United States during the late 1980s and early 1990s. There have been an increasing number of VRE cases throughout United States hospitals, and a proportionately higher incidence in the intensive care unit (ICU). As of 1997, approximately one quarter of all ICU enterococcal infections are resistant to vancomycin. Over the past fifteen to twenty years, this epidemic increase corresponds to an excessive use of vancomycin; initially, however, this was thought to be due to indiscriminate use of third-generation cephalosporins. Enterococci have an intrinsic resistance to antibiotics that is an acquired resistance from mutation and/or acquisition of foreign genetic materials by plasmids or transposons. At present, Enterococcus is the second most common nosocomial pathogen for urinary and wound infections, and the third most common for bloodstream infections. Originally, enterococci were not thought to be pathogenic. The attributable mortality due to enterococcal infection alone is still of current debate, as several studies are unable to accurately attribute mortality to enterococcal infection. Nevertheless, the associated mortality rate for inadequately treated nosocomial infections is 42%, versus 17% with adequate treatment, and more specifically, 59% for VRE infection and 61% for Candida sepsis. Additionally, with the increase in resistance, this translates into a longer intensive care unit hospital stay and an increase in the cost of health care. In 1995, the Centers for Disease Control (CDC) recommended guidelines to reduce nosocomial transmission of VRE that include antibiotic control; personnel education in regard to VRE case surveillance and contact isolation; universal precautions; and hand washing; as well as cleansing and disinfection of hospital rooms by housekeeping. We retrospectively evaluated: (1) The incide nce and prevalence of enterococcal infection in the SICU; (2) the risk factors for enterococcal infection and enterococcal-associated mortality with regard to Vancomycin susceptibility or resistance; and (3)if any change in incidence, prevalence, risks of infection, and associated mortality can be affected by hospital policy implementation, such as antibiotic restriction/formulary and adherence to strict contact-isolation guidelines as set forth by the CDC. We reviewed the medical records of patients seen between January 1, 1995 and December 31, 2000 at Howard University Hospital (HUH), a level I trauma center and tertiary care facility. 3) We performed a retrospective computerized microbiology database query 4) for all documented and confirmed cases of enterococcal infection of surgical patients cared for in the SICU at HUH including all body sites (eg, blood, urine, sputum) and antimicrobial sensitivity. Chart review was done to determine age, race, length of stay in both the hospital and the ICU, comorbid conditions, major and minor surgery, urinary catheters, ventilator support, antibiotic administration, immunosuppression, nutritional status, enterococcal infection and degree of vancomycin and other antibiotic resistance, other infections, complications, and outcome (defined as alive or dead at time of discharge). During this retrospective analysis from 1995 to 2000 we identified 4,539 SICU admissions, of which 175 patients were retrospectively documented as having an enterococcal infection using a retrospective microbiology database query. Eighty-six patients were male; of these 83 were African American, 2 were Hispanic, and 1 was Caucasian Eighty-nine of the patients were female; of these 86 were AfricanAmerican, 1 was Hispanic, and 1 was Caucasian. Mean age was 59 years, (median, 59 years; range, 24-94 years). 321 cultures were obtained from the 175 patients. From these 321 cultures, a total of 342 organisms were isolated. Forty-eight percent of all isolates were Enterococcus faecalis (170 isolates) and 3 8% were Enterococcus faecium (140 isolates). This differed from what is seen nationally, where Enterococcus faecalis accounts for 80% and Enterococcus faecium accounts 15% of all enterococcal infection. The urine and blood were the most commonly isolated sites, comprising 38% and 35% of all sites cultured, respectively. More than six years after implementation of strict contact isolation, one-to-one nursing practices, and antibiotic restrictions, we noted this resulted in a 66% decrease in the total number of isolates, from 92 in 1995 to 29 in 2000. Additionally the percentage of VRE among all isolates also decreased from 46% to 38%. In regard to patient infection and mortality, there are 50% less patients (43 vs. 22) identified comparing 1995 to 2000 and 50% less SICU-associated enterococcal deaths (21 deaths in 1995 vs 12 deaths in 2000). However, the crude mortality rate rose slightly from 49% in 1995 to 55% in 2000, even though we have decreased the number of patients with the infection and the number of deaths. This is not a reflection of decrease in patient numbers, as the total number of SICU admissions has risen steadily from 639 patient admissions in 1995 to 852 patient admissions in 2000, while the total number SICU patient deaths has remained relatively unchanged at 54 patient deaths in 1995 at 52 patient deaths in 2000. The overall six-year HUH SICU mortality rate from 1995 to 2000 was 7.5% (339 deaths for 4539 SICU admissions) for all SICU patients. The crude enterococcal-associated patient mortality rate was 53% (94 enterococcal-associated patient deaths of all 175 enterococcal identified patients in the SICU at HUH). Enterococcal nosocomial infections are rising. Enterococcus remains a controversial pathogen. The literature suggests an inadequately treated enterococcal infection results in a longer hospital and ICU stay and higher hospital costs, and especially, VRE infection has been controversially associated with a higher mortality rate. In order to decrease the incidence of enterococcal infecti on and vancomycin-resistant organisms, it is imperative to restrict antibiotic use and to maintain strict adherence to isolation protocol as recommended by the CDC, as evidenced by the total decrease in Enterococcus-infected patients, enterococcal isolates, nosocomial spread and overall mortality The ratio of infection to mortality has not changed, however. As enterococcal infection rates continue to rise and antibiotic resistance continues to develop, the numbert of available antibiotics to treat gram-positive infections is growing smaller. Maintaining the ability to treat these infections requires protocols to decrease infection spread, minimize the emergence of resistance, and, most importantly, avoiding transmission of genetic resistance to other potentially dangerous pathogens.

POSTPARTUM PARASITIC APPENDICITIS AND SEPTIC PELVIC THROMBOPHLEBITIS Deborah K. Cunningham, MD, V. Suzanne Williams, MD, M. R. Bergner, MD, A. Wiedower-Lamb, MD, M. Miller, MD, and V. S. Klimberg, MD. University of Arkansas for Medical Sciences, Little Rock, AR.

Appendicitis in the postpartum period is rare and difficult to diagnose. Most modem surgical textbooks do not include thrombosis of pelvic veins in the differential diagnosis of appendicitis. We report a case of septic pelvic thrombophlebitis (SPT) and parasitic appendicitis in a patient who was two weeks postpartum. A 20-year-old woman was evaluated for right lower quadrant abdominal pain with a palpable mass, fever, and leukocytosis two weeks after low forceps vaginal delivery. Computed tomography demonstrated and infracecal phlegmon with a circular enhancing lesion in the posterior aspect, thought to represent the appendix. Intraoperatively, the appendix appeared grossly normal. Further inspection revealed a 4 x 4.5-cm indurated mass encompassing the right broad ligament, extending above the pelvic brim, and right hydrosalpinx consistent with ovarian-vein thrombosis. Following appendectomy, the abdomen was closed. Antibiotic therapy was continued and heparin therapy was begun, with prompt resolution of sym ptoms. Pathologic examination of the appendix revealed a thickened wall with an appendicolith and pinworms, but no frank infection. Septic pelvic thrombophlebitis can mimic appendicitis, resulting in an operation for a disease that is preferentially treated nonoperatively. Diagnostic difficulties arise in the postpartum period because of abdominal symptoms thought to be related to recent pregnancy. Clinically, SPT should be suspected in women who are 2 to 3 days postpartum with nausea, vomiting, abdominal pain, fever, and a pelvic or abdominal mass, or in women with metritis and persistent fever. MRI is helpful for diagnosing SPT when computed tomography is equivocal. Treatment should include intravenous antibiotics and heparin with close observation. Surgical resection of thrombosed pelvic veins is reserved for cases refractory to medical management.

THE CHEST WALL ARTERIOVENOUS GRAFT: AN ALTERNATIVE TERTIARY ACCESS PROCEDURE. Ajay Pravin Patel, MD, and David Cull, MD. Greenville, SC.

Surgeons are increasingly challenged to provide arteriovenous (AV) access in patients in whom options for access in the upper extremity have been expended. Although the thigh AV graft is considered the procedure of choice for these patients, its morbidity is significant, including an 18% to 35% infection rate. To obviate the substantial morbidity associated with the thigh graft, we have preferentially placed chest wall or ipsilateral axillo-axillary grafts in patients in whom an upper extremity graft is not possible. The purpose of this report is to review our technique for chest wall AV graft placement and to review its patency and morbidity. A retrospective review of the vascular surgery registry at the Greenville Hospital System was performed. Between June 1998 and March 2001, eighteen chest wall grafts were placed in sixteen patients. There were 10 females and 6 males. Ten patients had diabetes and 10 had peripheral vascular disease. A mean of 20 (range, 10-55) access procedures were performed prior to ch est wall graft placement. Follow up was complete in all patients. There were 5 (31%) deaths in our series. One death was related to an infected chest wall AV graft and one was related to an infected thigh AV graft. Primary graft patency was 60% at 1 year by life-table analysis. The mean number of thrombectomies/revisions per patient was 0.87. There were 3 graft infections and 2 hematomas requiring operative drainage. There were no cases of arterial steal or congestive heart failure. The chest wall AV graft is a relatively easy procedure to perform and has a graft patency and complication rate which compares favorably with the thigh AV graft.

CONCURRENT OVARIAN TORSION AND APPENDICITIS IN A 5-YEAR OLD FEMALE: A CASE REPORT. Ray K Veeramasuneni, MD, Stanislaw P. Stawicki, MD, Michael D. Grossman, MD, James F. Reed III, PhD, Harry L. Anderson, MD, and Brian A. Hoey, MD. Department of Surgery, St. Luke's Hospital and Health Network, Bethlehem, PA.

Ovarian, torsion (OT) is an uncommon cause of abdominal pain in girls and is difficult to differentiate from other conditions causing lower abdominal pain. Acute adnexal pathology associated with concurrent appendicitis is even less common. We present a case of a 5-year-old girl who presented with acute lower abdominal pain and was found to have OT and appendicitis. Our patient presented with 3-day history of abdominal pain. Her pain was initially localized to her right lower quadrant (RLQ) and was most intense just superior to her pubis. Treatment with trimethoprim/sulfamethoxazole was begun one day before admission by her primary care physician for presumed urinary tract infection. Her symptoms gradually increased, with worsening pain, nausea, and vomiting. She had a temperature of 101[degrees]F the night prior to admission. She had poor appetite, and her last bowel movement was on the day before admission. On presentation, she had a temperature of 97.7[degrees]F; pulse, 85 beats/mm; respiration, 22 breaths /min; blood pressure 96/68 mm Hg. Her mucous membranes were moderately dry; her lungs were clear to auscultation. Her abdomen was flat, soft, and nondistended. She had mild RLQ tenderness and right suprapubic pain, but no rebound or guarding. Her WBC count was 11.1 x [10.sup.3]/[micro]L (55 segs, 15 monos, 0 bands). No other laboratory test abnormalities were noted. Initial CT scan of her abdomen and pelvis showed pericecal inflammation and an abnormal collection in her right pelvis, likely representing an abscess. She was treated with antibiotics. Interventional radiology service was consulted for percutaneous drainage of the collection; they did not feel that they could access it because of its location. The patient was improving with antibiotic treatment. A clear liquid diet was started on hospital day 2. Later the second day, she became febrile to 101.4[degrees]F. A second CT scan was obtained; the radiologist now believed that there was a solid mass, not abscess, in her RLQ. An ultrasound (US) examinatio n was done to better characterize the mass. The US demonstrated a normal appendix with a heterogeneous mass just inferior to the appendiceal tip. A color Doppler study showed no blood flow to the mass, but there was flow present around the mass. She was taken to the operating room for an exploratory laparotomy. Operative findings included the right ovary twisted around the distal third of the patient's appendix. The distal appendix was edematous and partially necrosed. The patient underwent an appendectomy and right salpingo-oophorectomy. The final pathologic diagnosis was consistent with right ovarian torsion and focal acute appendicitis. She was well at the 4-week follow-up examination. This case demonstrates the difficulties in diagnosing acute abdominal pain in the pediatric female population. Despite its rarity, ovarian torsion should always be considered in the differential diagnosis. Duplex ultrasonography is helpful to further characterize findings on CT scan that are not clearly consistent with acute appendicitis.

CYSTOSARCOMA PHYLLODES: A CASE REPORT OF SARCOMATOUS OVERGROWTH IN A MALIGNANT PHYLLODES TUMOR Marlon Alex Guerrero, and Ana M. Grau, MD. Department of Surgery, Meharry Medical College, Nashville, TN.

Cystosarcoma phyllodes constitutes only 0.3 to 0.9% of all breast tumors. The term sarcoma was used because of its fleshy appearance and a more modern term is phyllodes tumor (PT). The behavior of PT corresponds to a spectrum from benign and locally recurrent to malignant and metastatic. In a general surgical series, 6.2% of the tumors were malignant. A 96-year-old woman presented with an expanding left breast mass, rapidly increasing in size, becoming exudative in nature. On physical examination, a fungating, friable, and tender mass was observed covering the entire left breast. Palpation of lymphatic basins revealed no adenopathy. Chest x-ray films indicated no signs of metastases. It was elected to proceed with a wide excision of the mass under general anesthesia. The specimen measured 17 x 13 cm. Pathologic examination confirmed the mass to be a fibrosarcomatous overgrowth in a malignant phyllodes tumor. Discussion: PT presents as a painless breast mass. Skin ulceration due to ischemia may be present. The metastatic spread of these tumors is mainly hematogenous, so lymph nodes are rarely involved. The microscopic appearance of PT is that of epithelial elements and connective-tissue stroma. Malignancy is determined by characteristics of the stroma. Wide local excision with 2-cm margins is the treatment of choice, except for larger lesions, for which total mastectomy may be required. Axillary dissection for a clinically negative axilla is not recommended. The natural history of both benign and malignant PT is that of local recurrence in 20%. 25% of malignant PTs metastasize, typically to lungs, bones, and liver. There is no proven benefit of radiation therapy o